AI That Protects Patients and Strengthens Hospice Integrity
Empowering hospices with intelligent auditing and predictive analytics — ensuring every dollar supports the right patient, at the right time, for the right reasons.
Try the Compassionate Care Advisor
Ask questions about hospice eligibility, fraud detection, compliance, or any aspect of our AI solution
The Problem
Hospice care was founded on compassion, but across the U.S. it faces a crisis of integrity:
Exponential Growth Issues
Exponential growth in hospice providers with flat patient numbers
Rising Medicare Spending
Medicare spending rose from $20.5B in 2019 to $25B in 2023
Inappropriate Admissions
Live discharge rates increased to 18.2% in 2023, signaling inappropriate admissions
Fraud & Billing Abuse
Over $1.2B in non-hospice spending among hospice-enrolled patients, rising rates of fraud
Traditional auditing methods cannot keep pace with these issues — the system demands continuous, intelligent oversight.
The Solution: AI-Driven Oversight
The Hospice AI Advisor leverages machine learning to detect fraud, improve compliance, and ensure ethical hospice admissions.
Continuous Monitoring
Tracks claims in real-time to identify anomalies
Automated Compliance
Cross-checks hospice claims with CMS criteria instantly
Predictive Eligibility
Uses patient data to forecast when hospice care will be appropriate
Fraud Detection
Flags unusual billing or discharge patterns
Insightful Reporting
Generates reports that improve CMS oversight and provider trust
How It Works
Four seamless steps to transform hospice oversight
Integrate
Connect seamlessly with hospice EHR and billing systems
Analyze
AI reviews documentation, diagnoses, and utilization trends
Alert
Identifies fraud signals or early eligibility indicators
Report
Produces actionable data dashboards for decision-makers
Measurable Benefits
Proven improvements for hospices, CMS, and patients
85%
Reduction in Inappropriate Admissions
AI-powered eligibility screening ensures only appropriate patients are admitted to hospice care
$2.3M
Average Annual Savings
Per healthcare system through improved compliance and reduced audit penalties
92%
Fraud Detection Accuracy
Industry-leading precision in identifying billing irregularities and documentation fraud
AI in Action
Real examples of fraud detection and compliance prediction
🚨 Fraud Detection Alert
Pattern Detected: Unusual Discharge Timing
Provider XYZ shows 47% live discharge rate vs. industry average of 18.2%. AI flagged 23 cases with similar patterns suggesting potential inappropriate admissions.
✅ Compliance Prediction
Early Eligibility Indicator
Patient Jane D. (DOB: XX/XX/XXXX) shows prognostic indicators suggesting 6-month life expectancy. Current treatment trajectory aligns with hospice appropriateness criteria.
📊 Documentation Analysis
Missing Documentation Alert
Claims submitted for Patient ID #12345 missing required physician certification. CMS audit risk increased by 34% without proper documentation.
About Compassionate Solutions
Founded on the principle that technology should enhance, not replace, the human element in healthcare. Our mission is to use AI to create ethical and efficient hospice care — reducing fraud while ensuring patients who need hospice get the right support at the right time.
Ethical AI
Built with fairness, transparency, and clinical oversight as core principles
Patient-Centered
Every feature designed to improve patient care and family support
Compliance First
Helping providers meet CMS requirements while reducing administrative burden
Partners & Compliance
Aligned with industry standards and regulatory requirements
CMS Alignment
Medicare Guidelines Compliance
Built on current CMS hospice eligibility criteria and billing requirements
Quality Reporting Integration
Supports CAHPS and HIS quality measure reporting
Audit Preparation Support
Automated documentation review for CMS compliance audits
Security & Privacy
HIPAA Compliant
End-to-end encryption and secure data handling protocols
SOC 2 Type II Certified
Rigorous security controls and annual compliance audits
Zero Data Retention
Patient data processed and purged according to retention policies
Comprehensive Hospice Eligibility Criteria
CMS-compliant assessment guidelines built into our AI system
Core Eligibility Requirements
6-Month Prognosis
Terminal illness with 6-month life expectancy if disease runs normal course
Physician Certification
Attending physician + hospice medical director certification required
Patient Election
Informed consent and election of hospice care by patient/family
Comfort Care Focus
Emphasis on comfort care versus curative treatment approaches
Functional Decline Indicators
Performance Scales
- • Karnofsky ≤50%
- • ECOG ≥3
- • Dependence in 3+ ADLs
Physical Decline
- • Recurrent falls
- • Decreased ambulation
- • Progressive weakness
Nutritional Status
- • Weight loss >10% in 6 months
- • Albumin <2.5 g/dL
- • Declining oral intake
Disease-Specific Eligibility Criteria
Cancer
- • Metastatic or locally advanced disease
- • Karnofsky ≤50% or ECOG ≥3
- • Treatment failure or refusal
- • Declining performance status
Cardiac
- • NYHA Class IV heart failure
- • Ejection fraction ≤20%
- • 3+ hospitalizations in 12 months
- • Optimal therapy maximized
Pulmonary
- • FEV1 <30% predicted
- • O2 saturation ≤88% on O2
- • Cor pulmonale
- • Recurrent pneumonia
Neurological
- • Advanced dementia (FAST 7C)
- • Unable to ambulate/dress/bathe
- • Minimal verbal communication
- • Recurrent infections
Renal
- • CrCl <10 mL/min
- • Serum creatinine >8.0 mg/dL
- • Dialysis refusal/discontinuation
- • Uremia, hyperkalemia
Liver
- • Cirrhosis with complications
- • Refractory ascites
- • Spontaneous bacterial peritonitis
- • Hepatorenal syndrome
Documentation Requirements
Required Documentation
- Initial physician certification within 15 days
- Face-to-face encounter within 30 days (recertification)
- Clinical notes supporting terminal prognosis
- Care plan focusing on comfort measures
- Patient election statement with informed consent
Red Flags (Inappropriate Admissions)
- Stable chronic conditions without decline
- Active curative treatment ongoing
- Functional status too high (Karnofsky >50%)
- Admission for social/convenience reasons
- Lack of terminal diagnosis documentation
AI Assessment Response Format
Our AI provides structured, clinical assessments using this format:
1. Eligibility Determination
ELIGIBLE / NOT ELIGIBLE / NEEDS DOCUMENTATION
2. Supporting Criteria
Specific indicators met or missing
3. Missing Elements
Required documentation gaps
4. Regulatory Compliance
CMS requirement status
Advanced Clinical Assessment Tools
Specialized scoring systems and frameworks integrated into our AI analysis
Performance & Functional Assessment
Karnofsky Performance Scale
- 100-80: Normal activity, minor symptoms
- 70-50: Cannot work, considerable assistance
- 40-20: Disabled, requires special care
- ≤50%: Hospice Eligible
ECOG Performance Status
- 0: Fully active, no restrictions
- 1: Restricted in strenuous activity
- 2: Ambulatory, up >50% of time
- ≥3: Hospice Eligible
FAST Scale (Dementia)
- Stage 6: Basic ADL assistance needed
- Stage 7A: Limited vocabulary (<6 words)
- Stage 7C: Hospice Eligible
- Cannot walk, sit up, smile, or hold head up
Disease-Specific Assessment Frameworks
Cardiac Assessment (NYHA Classification)
Class I-II
Minimal limitations, comfortable at rest
Class III
Marked limitation, less than ordinary activity
Class IV
Hospice Eligible: Symptoms at rest
Pulmonary Assessment (GOLD Staging)
GOLD 1-2
FEV1 >50%, mild-moderate limitation
GOLD 3
FEV1 30-50%, severe limitation
GOLD 4
Hospice Eligible: FEV1 <30%
Laboratory & Biomarker Indicators
Nutritional Markers
- Albumin:<2.5 g/dL
- Prealbumin:<10 mg/dL
- Weight Loss:>10% in 6 months
- BMI:<18.5
Renal Function
- Creatinine:>8.0 mg/dL
- CrCl:<10 mL/min
- BUN:>80 mg/dL
- Urine Output:<400 mL/day
Cardiac Markers
- Ejection Fraction:≤20%
- BNP:>400 pg/mL
- Troponin:Persistently elevated
- Sodium:<130 mEq/L
Advanced Prognostic Indicators
Surprise Question
"Would I be surprised if this patient died within 6-12 months?"
Answer "No" = Consider hospice
Decline Trajectory
Progressive functional decline over 3-6 months
Multiple hospitalizations
Treatment Response
Diminishing response to optimal therapy
Side effects outweigh benefits
Quality of Life
Significant symptom burden impacting daily life
Family/patient goals shift to comfort
Regulatory Compliance Framework
CMS guidelines and Medicare requirements integrated into our AI system
Medicare Coverage Criteria (42 CFR 418)
Certification Requirements
Initial Certification
Attending physician + hospice medical director within 15 days
Recertification
Face-to-face encounter within 30 days prior to 3rd benefit period
Narrative Statement
Clinical findings supporting 6-month prognosis
Benefit Periods
Initial Period
90 days - Physician certification required
Subsequent Period
90 days - Physician certification required
Extended Periods
60 days each - Face-to-face + certification required
Quality Reporting & Audit Compliance
CAHPS Hospice Survey
- • Communication with family
- • Emotional support provided
- • Help with pain and symptoms
- • Training family to care for patient
- • Rating of hospice care
HIS Quality Measures
- • Patients treated with opioids who are given bowel regimen
- • Patients who believe they got right amount of medicine for pain
- • Patients whose shortness of breath was addressed
- • Patients treated with appropriate level of care
Documentation Standards
- • Plan of care updates every 15 days
- • Interdisciplinary team meetings
- • Medication management records
- • Family conference documentation
- • Volunteer contact logs
AI-Powered Fraud Prevention Indicators
Length of Stay Anomalies
Unusually long stays without clinical justification
Live Discharge Patterns
High rates of patients discharged alive after short stays
Diagnosis Clustering
Overconcentration in specific, profitable diagnoses
Documentation Gaps
Missing face-to-face encounters or certifications
Resources & Insights
Latest research and data supporting AI in hospice care
📊 Featured Report: Hospice Monitoring Report 2024
Comprehensive analysis of hospice care trends, compliance challenges, and opportunities for AI-driven improvements in the healthcare system.
Download Full Report (PDF)CMS Data Analysis
Our analysis of 2019-2023 Medicare hospice spending data reveals critical trends in inappropriate utilization and billing patterns.
Read Full ReportAI in Healthcare White Paper
Comprehensive guide to implementing machine learning for healthcare fraud detection and compliance monitoring.
Download PDFIndustry Best Practices
Evidence-based recommendations for hospice providers to improve compliance and patient outcomes through technology.
View GuidelinesAdditional Resources
📈 Market Research
Quarterly reports on hospice industry trends and regulatory changes
🔬 Technical Documentation
API documentation and integration guides for healthcare systems